Pregnancy at Risk: Pregestational Onset

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Pregnancy at Risk Pregestational Onset
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Alcohol Use in Pregnancy

• Maternal effects
• Malnutrition
• Bone-marrow suppression
• Increased incidence of infections
• Liver disease
• Neonatal effects
• Fetal alcohol spectrum disorders (FASD)

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Cocaine Use in Pregnancy Maternal Effects

• Seizures and hallucinations
• Pulmonary edema
• Respiratory failure
• Cardiac problems
• Spontaneous first trimester abortion, abruptio
  placentae, intrauterine growth restriction
  (IUGR), preterm birth, and stillbirth

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Cocaine Use in Pregnancy Fetal Effects

• Decreased birth weight and head circumference
• Feeding difficulties
• Neonatal effects from breast milk
• Extreme irritability
• Vomiting and diarrhea
• Dilated pupils and apnea

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Heroin Use in Pregnancy

• Maternal effects
• Poor nutrition and iron-deficiency anemia
• Preeclampsia-eclampsia
• Breech position
• Abnormal placental implantation
• Abruptio placentae
• Preterm labor

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Heroin Use in Pregnancy (contd)

• Maternal effects
• Premature rupture of the membranes (PROM)
• Meconium staining
• Higher incidence of STIs and HIV
• Fetal effects
• IUGR
• Withdrawal symptoms after birth

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Substance Use in Pregnancy Maternal Effects

• Marijuana difficult to evaluate, no known
  teratogenic effects
• PCP - maternal overdose or a psychotic response
• MDMA (Ecstasy) - long-term impaired memory and
  learning

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Pathology of Diabetes Mellitus (DM)

• Endocrine disorder of carbohydrate metabolism
• Results from inadequate production or utilization
  of insulin
• Cellular and extracellular dehydration
• Breakdown of fats and proteins for energy

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Gestational Diabetes (GDM)

• Carbohydrate intolerance of variable severity
• Causes
• An unidentified preexistent disease
• The effect of pregnancy on a compensated
  metabolic abnormality
• A consequence of altered metabolism from changing
  hormonal levels

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Effect of Pregnancy on Carbohydrate Metabolism

• Early pregnancy
• Increased insulin production and tissue
  sensitivity
• Second half of pregnancy
• Increased peripheral resistance to insulin

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Maternal Risks with DM

• Hydramnios
• Preeclampsia-eclampsia
• Ketoacidosis
• Dystocia
• Increased susceptibility to infections

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Fetal and Neonatal Risks with DM

• Perinatal mortality
• Congenital anomalies
• Macrosomia
• IUGR
• RDS
• Polycythemia

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Fetal and Neonatal Risks with DM (contd)

• Hyperbilirubinemia
• Hypocalcemia

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Screening for DM in Pregnancy

• Assess risk at first visit
• Low risk - screen at 24 to 28 weeks
• High risk - screen as early as feasible

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Risk Factors

• Age over 40
• Family history of diabetes in a first-degree
  relative
• Prior macrosomic, malformed, or stillborn infant
• Obesity
• Hypertension
• Glucosuria

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Screening Tests

• One-hour glucose tolerance test
• Level greater than 130-140 mg/dl requires further
  testing
• 3-hour glucose tolerance test
• GDM diagnosed if 2 levels are exceeded

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Treatment Goals

• Maintain a physiologic equilibrium of insulin
  availability and glucose utilization
• Ensure an optimally healthy mother and newborn
• Treatment
• Diet therapy and exercise
• Glucose monitoring
• Insulin therapy

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Fetal Assessment

• AFP
• Fetal activity monitoring
• NST
• Biophysical profile
• Ultrasound

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Nursing Management

• Assessment of glucose
• Nutrition counseling
• Education about the disease process and
  management
• Education about glucose monitoring and insulin
  administration
• Assessment of the fetus
• Support

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Iron-deficiency Anemia

• Maternal complications
• Susceptible to infection
• May tire easily
• Increased chance of preeclampsia and postpartal
  hemorrhage
• Tolerates poorly even minimal blood loss during
  birth

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Iron-deficiency Anemia (contd)

• Fetal complications
• Low birth weight
• Prematurity
• Stillbirth
• Neonatal death

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Iron Deficiency Anemia (contd)

• Prevention and treatment
• Prevention - at least 27 mg of iron daily
• Treatment - 60-120 mg of iron daily

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Folate Deficiency

• Maternal complications
• Nausea, vomiting, and anorexia
• Fetal complications
• Neural tube defects
• Prevention - 4 mg folic acid daily
• Treatment - 1 mg folic acid daily plus iron
  supplements

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Folate Deficiency

• Maternal complications
• Nausea, vomiting, and anorexia
• Fetal complications
• Neural tube defects
• Prevention - 4 mg folic acid daily
• Treatment - 1 mg folic acid daily plus iron
  supplements

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Sickle Cell Anemia

• Maternal complications
• Vaso-occlusive crisis
• Infections
• Congestive heart failure
• Renal failure

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Sickle Cell Anemia (contd)

• Fetal complications include fetal death,
  prematurity, and IUGR.
• Treatment
• Folic acid
• Prompt treatment of infections
• Prompt treatment of vaso-occlusive crisis

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Thalassemia

• Treatment
• Folic acid
• Transfusion
• Chelation

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HIV in Pregnancy

• Asymptomatic women - pregnancy has no effect
• Symptomatic with low CD4 count - pregnancy
  accelerates the disease
• Zidovudine (ZDV) therapy diminishes risk of
  transmission to fetus
• Transmitted through breast milk
• Half of all neonatal infections occurs during
  labor and birth

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HIV in Pregnancy Maternal Risks

• Intrapartal or postpartal hemorrhage
• Postpartal infection
• Poor wound healing
• Infections of the genitourinary tract

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HIV Effects on Fetus

• Infants will often have a positive antibody titer
• Infected infants are usually asymptomatic but are
  likely to be
• Premature
• Low birth weight
• Small for gestational age (SGA)

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Treatment DuringPregnancy

• Counsel about implications of diagnosis on
  pregnancy
• Antiretroviral therapy
• Fetal testing
• Cesarean birth

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Cardiac Disorders in Pregnancy

• Congenital heart disease
• Marfan syndrome
• Peripartum cardiomyopathy
• Eisenmenger syndrome
• Mitral valve prolapse

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Less Common Medical Conditions in Pregnancy

• Rheumatoid arthritis
• Epilepsy
• Hepatitis B
• Hyperthyroidism
• Hypothyroidism
• Maternal phenylketonuria

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Less Common Medical Conditions in Pregnancy
(contd)

• Multiple sclerosis
• Systemic lupus erythematosus
• Tuberculosis

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Pregnancy at Risk Gestational Onset
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Spontaneous Abortion

• Threatened abortion
• Imminent abortion
• Incomplete abortion
• Complete abortion

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Types of spontaneous abortion. A Threatened The
cervix is not dilated, and the placenta is still
attached to the uterine wall, but some bleeding
occurs.
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B Imminent. The placenta has separated from the
uterine wall, the cervix has dilated, and the
amount of bleeding has increased.
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C Incomplete. The embryo/fetus has passed out of
the uterus however, the placenta remains.
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Spontaneous Abortion (contd)

• Missed abortion
• Recurrent pregnancy loss
• Septic abortion

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Spontaneous Abortion Treatment

• Bed rest
• Abstinence from coitus
• DC or suction evacuation
• Rh immune globulin

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Spontaneous Abortion Nursing Care

• Assess the amount and appearance of any vaginal
  bleeding
• Monitor the womans vital signs and degree of
  discomfort
• Assess need for Rh immune globulin.
• Assess fetal heart rate
• Assess the responses and coping of the woman and
  her family

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Ectopic Pregnancy Risk Factors

• Tubal damage
• Previous pelvic or tubal surgery
• Endometriosis
• Previous ectopic pregnancy
• Presence of an IUD
• High levels of progesterone

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Ectopic Pregnancy Risk Factors (contd)

• Congenital anomalies of the tube
• Use of ovulation-inducing drugs
• Primary infertility
• Smoking
• Advanced maternal age

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Ectopic Pregnancy Treatment

• Methotrexate
• Surgery

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Various implantation sites in ectopic pregnancy.
The most common site is within the fallopian
tube, hence the name tubal pregnancy
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Ectopic Pregnancy Nursing Care

• Assess the appearance and amount of vaginal
  bleeding
• Monitors vital signs
• Assess the womans emotional status and coping
  abilities
• Evaluate the couples informational needs.
• Provide post-operative care

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Gestational Trophoblastic Disease Symptoms

• Vaginal bleeding
• Anemia
• Passing of hydropic vesicles
• Uterine enlargement greater than expected for
  gestational age
• Absence of fetal heart sounds
• Elevated hCG

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Gestational Trophoblastic Disease Symptoms

• Low levels of MSAFP
• Hyperemesis gravidarum
• Preeclampsia

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Gestational Trophoblastic Disease Treatment

• DC
• Possible hysterectomy
• Careful follow-up

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Hydatidiform mole. A common sign is vaginal
bleeding, often brownish (the characteristic
prune juice appearance) but sometimes bright
red. In this figure, some of the hydropic vessels
are being passed. This occurrence is diagnostic
for hydatidiform mole.
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Gestational Trophoblastic Disease Nursing Care

• Monitor vital signs
• Monitor vaginal bleeding
• Assess abdominal pain
• Assess the womans emotional state and coping
  ability

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Bleeding Disorders

• Placenta previa - placenta is improperly
  implanted in the lower uterine segment
• Abruptio placentae - premature separation of a
  normally implanted placenta from the uterine wall

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Cervical Incompetence Treatment

• Serial cervical ultrasound assessments
• Bed rest
• Progesterone supplementation
• Antibiotics
• Anti-inflammatory drugs
• Cerclage procedures

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A cerclage or purse-string suture is inserted in
the cervix to prevent preterm cervical dilatation
and pregnancy loss. After placement, the string
is tightened and secured anteriorly.
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Hyperemesis Gravidarum Treatment

• Control vomiting
• Correct dehydration
• Restore electrolyte balance
• Maintain adequate nutrition

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Hyperemesis Gravidarum Nursing Care

• Assess the amount and character of further emesis
• Assess intake and output and weight.
• Assess fetal heart rate
• Assess maternal vital signs
• Observe for evidence of jaundice or bleeding
• Assess the womans emotional state

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Nursing Care of Clients with PROM

• Determine duration of PROM
• Assess gestational age
• Observe for signs and symptoms of infection
• Assess hydration status
• Assess fetal status
• Assess childbirth preparation and coping

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Nursing Clients with PROM (contd)

• Encourage resting on left side
• Provide comfort measures
• Provide education

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Nursing Care of Clients with Preterm Labor

• Identify risk for preterm labor
• Assess change in risk status for preterm labor
• Assess educational needs of the woman and her
  loved ones
• Assess the womans responses to medical and
  nursing intervention
• Teach about the importance of recognizing the
  onset of labor

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Signs and Symptoms of Preterm Labor

• Uterine contractions occurring every 10 minutes
  or less
• Mild menstrual like cramps felt low in the
  adbomen
• Constant or intermittent feeling of pelvic
  pressure
• Rupture of membranes
• Low, dull backache, which may be constant or
  intermittent

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Signs and Symptoms of Preterm Labor (contd)

• A change in vaginal discharge
• Abdominal cramping with or without diarrhea

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Classification of Hypertension in Pregnancy

• Preeclampsia-eclampsia
• Chronic hypertension
• Chronic hypertension with superimposed
  preeclampsia
• Gestational hypertension

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Chronic Hypertension in Pregnancy

• Hypertension before 20 weeks without proteinurea
  or stable proteinurea
• At a higher risk for adverse outcomes
• At risk for development of pre-eclampsia

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Chronic Hypertension

• If target organ damage present, pregnancy can
  exacerbate the condition
• Lifestyle modifications
• - Activity restrictions
• - Weight reduction
• - Sodium restriction
• - ETOH and tobacco strongly discouraged

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Plan of Care Chronic Hypertension in Pregnancy

• Medications can safely be withheld in patients
• Without target organ damage
• Blood pressure less than 150-160 mmHg systolic
  and 100-110 diastolic

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Pharmacological management Chronic HTN in
Pregnancy

• Methyldopa (Aldomet) preferred alpha-2 adrenergic
  agonist
• Labetalol (normodyne, Trandate) beta blocker
• Diuretic, calcium antagonists, other beta
  blockers?
• ACE (angiotension converting enzyme) inhibitors
  are contraindicated in pregnancy IUGR,
  oligohydramnios, neonatal renal failure, and
  neonatal death
• ARB (angiotension receptor blockers)not
  researched in pregnancy but probably
  contraindicated

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Labatalol

• Baby at risk for transient hypotension and
  hypogylcemia if mom on labatalol
• No labatalol to clients with asthma or first
  degree heart block

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Fetal Assessment

• Fetal growth restriction
• Ultrasound _at_ 18-20 weeks, 28-32 weeks as needed
  thereafter
• NST or biophysical profile if growth restricted

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Preeclampsia-eclampsia

• Increased blood pressure AND proteinurea
• Highly suspected if increased BP and headache,
  blurred vision, abdominal pain, low platelets
  and/or abnormal liver enzymes

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MAP

• Mean Arterial Pressure average of systolic and
  diastolic blood pressure readings
• SBP DBP DBP
• 3
• ACOG states hypertension exists when there is an
  increase in the MAP of 20 mmHg, and if no
  baselines are known, a MAP of 105 mmHg is used
• Two readings 4-6 hours apart

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Hypertension in Pregnancy

• Hypertension complicates 5-7 of all pregnancies
• One-half to two-thirds have preeclampsia or
  eclampsia
• Hypertension is a leading cause of maternal and
  infant morbidity and mortality

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Normal Adaptations to Pregnancy

• Increased blood plasma volume
• Vasodilation
• Decreased systemic vascular resistance
• Elevated cardiac output
• Decreased colloid osmotic pressure

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Preeclamptic Changes in Pregnancy

• Renal lesions are present, especially in
  nulliparous women (85)
• Arteriolar vasospasm diminishes the diameter of
  the blood vessels which impedes blood flow to
  organs and raises blood pressure (perfusion to
  placenta, kidneys, liver, and brain can be
  diminished by 40-60)

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Etiology of Hypertension

• Vasospasms are one of the underlying mechanisms
  for the signs and symptoms of preeclampsia
• Endothelial damage (from decreased placental
  perfusion) contributes to preeclampsia
• With endothelial damage, arteriolar vasospasm may
  contribute to increased capillary permeability.
  This increases edema and decreases intravascular
  volume

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Other Suspected Causes

• The presence of foreign protein (placenta or
  fetus) may trigger an immunologic response
• This is supported by
• - the incidence of preeclampsia in first-time
  mothers (first exposure to fetal tissue)
• - women pregnant by a new partner (different
  genetic material)

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Pulmonary Preeclamptic Changes

• At risk for development of pulmonary edema
• Pulmonary capillaries susceptible to fluid
  leakage across membranes due to endothelial
  damage
• Left ventricular failure from increased afterload
  leading to backup of fluid in pulmonary bed

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Renal Preeclamptic Changes

• Reduced kidney perfusion decreases the glomerular
  filtration rate which lead to degenerative
  changes and oliguria
• Protein is lost in the urine, sodium and water
  are retained
• Fluid moves out of the intravascular compartment
  resulting in increased blood viscosity and tissue
  edema

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Vascular Preeclamptic Changes

• Hematocrit level rises as fluid leaves the cells
• Blood volume may fall to or below prepregnancy
  levels severe edema develops and weight gain is
  seen
• Decreased liver perfusion causes impaired
  function. Epigastric pain or RUQ pain

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More Preeclamptic Changes

• Arteriolar vasospasms with decreased blood
  perfusion to the retina causes visual changes
  such as blind spots and blurring
• CNS changes caused by spasms as well as edema
  include headache, hyperreflexia, positive ankle
  clonus, and occasionally the development of
  eclampsia

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Characteristics of Preeclampsia

• Maternal vasospasm
• Decreased perfusion to virtually all organs
• Decrease in plasma volume
• Activation of the coagulation cascade
• Alterations in glomerular capillary endothelium
• Edema

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Characteristics of Preeclampsia

• Increased viscosity of the blood
• Hyperreflexia
• Headache
• Subcapsular hematoma of the liver

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A In a normal pregnancy, the passive quality of
the spiral arteries permits increased blood flow
to the placenta.
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B In preeclampsia, vasoconstriction of the
myometrial segment of the spiral arteries occurs.
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What is the possible end result?

• Heart failure, caused by circulatory collapse and
  shock
• Pulmonary edema, associated with severe
  generalized edema (weak, rapid pulse, lowered
  blood pressure, crackles)
• HELLP Syndrome Multisystem disease in which
  hemolysis, elevated liver enzymes and low
  platelets are present
• Disseminated Intravascular Coagulation (DIC)
• Clotting factors are consumed by excess fluid,
  generalized bleeding occurs. Thrombocytopenia

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Differential Diagnosis

• BP of gt 160 systolic or gt 110 diastolic
• Proteinurea of 1-2 on 2 dipsticks at least 4
  hours apart or .3 grams or more in 24 hours
• Increased serum creatinine gt 1.2 unless prior
  elevation
• Platelet count less than 100,000
• Elevated ALT or AST
• Persistent headache or visual changes
• Persistent epigastric pain, nausea and vomiting

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Labs

• Hgb Hct hemoconcentration supports dx of
  preeclamsia and is an indicator of severity.
  Values may be decreased, however, if hemolysis
  accompanies the disease
• Platelets thrombocytopenia suggests severe
  preeclamsia
• Quantification of protein excretion if
  proteinurea should consider preeclamsia
• Serum creatinine abnormal rising levels
  especially in conjunction with oligurea
  (thickening of the renal arterioles)
• Serum uric acid increases as urate clearance
  decreases due to enlargement of glomerular
  endothelial cells and occlusions of capillary
  lumen
• Serum albumin hypoalbuminemia indicates extent
  of endothelial leak
• Coagulation profile coagulopathy including
  thrombocytopenia

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Specific Labs

• Preeclampsia HELLP
• Hctgt35 Hemolysis-burr
  
• Uric Acid gt 4.5mg cells present
• BUN gt 10mg/dl bili 1.2mg/d
• Plt lt150,000 SGOT gt72 U/L
• SGOT gt 41 U/L SGPT gt 50 U/L
• SGPT gt 30 U/L Plateletslt100,000

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Hypertensive Effects on Fetus

• Small for gestational age
• Fetal hypoxia
• Death related to abruption
• Prematurity

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Home Management

• Monitoring for signs and symptoms of worsening
  condition
• Fetal movement counts
• Frequent rest in the left lateral position
• Monitoring of blood pressure, weight, and urine
  protein daily
• NST
• Laboratory testing

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Management of Severe Preeclampsia

• Bed rest
• High-protein, moderate-sodium diet
• Treatment with magnesium sulfate
• Corticosteroids
• Fluid and electrolyte replacement
• Antihypertensive therapy

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Fetal Indications for Delivery

• Severe IUGR
• Nonreassuring fetal surveillance
• oligohydramnios

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Maternal Indications for Delivery

• Gestational age of 38 weeks or greater
• Platelet count below 100K
• Progressive deterioration of hepatic function
• Progressive deterioration of renal function
• Suspected placental abruption
• Persistent severe headache or visual changes
• Persistent severe epigastric pain, nausea, or
  vomiting
• eclampsia

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Plan of Care for the Preeclamptic

• Complete bedrest
• Left lying position-increases kidney glomerular
  function and urine output
• Provide darkened quiet room
• Limit visitation
• Fluid restriction (125-150ml/hr)
• Seizure precautions
• Magnesium sulfate
• Antihypertensives

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Preeclampsia Assessment

• Edema
• DTRs and clonus
• Assess fluid balance-strict I O
• Breath sounds (pulmonary edema)
• Vital signs BP, respiratory rate SaO2
• LOC
• c/o HA or visual disturbances
• Proteinurea
• Epigastric pain

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Edema

• 1 edema is minimal (2mm) at pedal and pretibial
  sites
• 2 (4mm) edema of lower extrmities is marked
• 3 (6mm) edema is evident in hands, face, lower
  abdominal wall and sacrum
• 4 (8mm) generalized massive edema is evident
  including ascites from accumulaton of fluid in
  the peritoneal cavity

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Assessment of CNS Changes

• DTRs and Clonus
• DTRs 0-4 patellar and brachial
• 0no response
• 1low normal
• 2average
• 3brisk
• 4hyperactive

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Clonus

• Extreme hyperreflexia
• Involuntary oscillations that may be seen between
  flexion and extension when continuous pressure is
  applied to the sole of the foot
• Counted in beats

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Plan of Care for the Preeclamptic

• Magnesium Sulfate used to prevent or control
  seizures-it is a CNS depressant and smooth muscle
  relaxant-increases blood flow to the fetus
• It does not treat the BP
• Interferes with the release of acetylcholine at
  the synapses, decreases neuromuscular irritability

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Magnesium Sulfate

• Loading dose 4-6 grams over 15-30 minutes
• Maintenance dose 1-2 grams/hour
• Therapeutic levels 4.8-9.6 mg/dl
• Always IVPB to mainline
• Calcium gluconate available as antidate

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Renal Insufficiency

• Magnesium sulfate is hazardous to women with
  severe renal failure and maintenance dose must be
  reduced

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Assessment of Patients on Magnesium Sulfate

• BP, pulse, and respiratory status should be
  monitored at least every 5 minutes with the
  loading dose, and every 15 minutes while on
  maintenance
• Continued the first 24 hours postpartum to
  prevent seizures
• Monitor I O 30ml/hr
• Serum levels every 4-6 hours therapeutic
  4.8-9.6 mg/dl

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Side Effects of Mag Sulfate

• Flushing
• Sweating
• Thirst
• Drying mucous membranes
• Depression of reflexes
• Muscle flaccidity
• Nausea
• Blurred visoin
• HA
• tachycardia

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Clinicial Manifestations of Hypermagnesemia

• Weakness
• Paresthesias
• Dcreased deep tendon reflexes
• Lethargy, confusion, disorientation
• Hypoventilatoin
• Seizures
• Paralysis
• Bradyarrythmias
• Heart block
• Decreased cardiac contractility
• Impaired protein synthesis
• Decreased skeletal mineralization
• Hepatic dysfunction

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Calcium Gluconate

• Antidote for mag sulfate
• 1 g of 10 calcium gluconate is administered slow
  IV push over 3 minutes and repeated every hour
  until signs and sxs of toxicity have been
  resolved
• Should be kept at the bedside

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Control of BP

• Antihypertensives may be needed to lower the
  diastolic pressure
• This reduces maternal mortality and morbidity
  associated with left ventricular failure and
  cerebral hemorrhage
• Placental perfusion is controlled by maternal
  blood pressure, drug must be calibrated carefully

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Antihypertensives

• If BP reaches 150/100 mmHg or higher
• Labatalol (alpha/beta adrenergic blocker)
• Begin with 20mg IVP slowly over 2 minutes
• Or continuous infusion of 1mg/kg can be used
• May double dose up to 80 mg every 15-20 minutes
• Maximum dose 220mg
• Apresoline (vasodilator)
• Begin with 5-20 mg infused over 2-4 minutes
• May be repeated every 20-30 minutes
• If no success by 20 mg IV or 30 mg IM try another
  drug

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Eclampsia

• Derives from the Greek word meaning like a flash
  of lightening
• a condition that seems to strike out of the blue
• 75 of the time it occurs intrapartum

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Eclampsia

• Characterized by seizures or coma
• Is a major hazard with poor outcomes in
• - gestations of less than 28 weeks
• - mothers older than 35 years of age
• - multigravidas
• - chronic HTN, renal disease or diabetes

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Eclampsia

• Rare in the Western world because doctors can
  diagnose the condition in its earliest phase
  (preeclampsia) and they are constantly on the
  alert for the warning signs
• Earliest signs drowsiness, HA, dimness of
  vision, rising BP, protein in the urine, edema,
  RUQ pain

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Etiology

• Cerebral vasospasm, hemorrhage or edema, platelet
  and fibrin clots occlude vasculature leading to
  seizure
• Blood vessels in the uterus go into spasm cutting
  blood flow to the baby
• Spasms lead to kidney failure
• Tissues become water-logged because of fluid
  retention
• Hemorrhages happen in the liver
• Brain oxygen levels are lowered causing
  heightened brain sensitivity which shows as
  seizures

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Signs and Symptoms of Impending Seizures

• Extreme hypertension 200/140 not uncommon
• Hyperreflexia
• 4 proteinurea
• Generalized marked edema
• Severe headache with or without visual
  distrubances

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Management of Care During a Seizure

• CALL FOR HELP!
• Immediate care Take care of the mother first
• -patent airway
• -adequate oxygenation
• -turn on side to prevent aspiration
• Magnesium Sulfate administration
• Assessment of the fetus, birth if threatened
• Steroid administration if fetal lungs are not
  mature

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PNEUMONIC

• S safety
• E establish airway
• I IV bolus
• Z zealous observation
• U uterine activity
• R rapid resuscitation
• E evaluate fetus

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Postictal State

• Central venous pressure monitoring
• Establish second indwelling catheter
• Blood glucose level to rule out hypogylcemia due
  to liver not functioning properly
• Blood should be available for emergency infusion
  due to abruptio
• Do not leave patient alone

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REMEMBER!!!

• All medications and therapy are merely temporary
  measures
• Delivery is the only cure

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Signs and Symptoms of Eclampsia

• Scotomata
• Blurred vision
• Epigastric pain
• Vomiting
• Persistent or severe headache
• Neurologic hyperactivity Pulmonary edema
• Cyanosis

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Management of Eclampsia

• Assess characteristics of seizure
• Assess status of the fetus
• Assess for signs of placental abruption
• Maintain airway and oxygenation
• Position on side to avoid aspiration
• Suction to keep the airway clear

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Management of Eclampsia (contd)

• To prevent injury, raise padded side rails
• Administer magnesium sulfate

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Postpartum Management

• Symptoms usually resolve within 48 hours of birth
• Lab abnormalities usually resolve from 72-96
  hours after birth
• Careful assessment continues, mag sulfate may
  continue to be infused for 12-48 hours after the
  birth
• Bleeding must be assessed

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Hemorrhage Hypertension

• NO Methergine
• Causes vasospasm and increases blood pressure
• CONTRAINDICATED in pts with HTN
• Use hemabate or cytotec for PPH

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Comparison of Risk Factors for HELLP Syndrome and
Preeclampsia

• HELLP Preeclampsia
• Multiparous Nulliparous
• Maternal age gt25 Maternal agelt20
• White or gt45
• Hx of poor preg Family hx
• Outcome Poor PNC
• 
  Diabetes
• Chronic
  HTN
• 
  Multiple gestation

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HELLP

• Hemolysis, Elevated liver enzymes, Low platelet
  count
• Prevalence is higher among older, white,
  multiparous women
• Carries a mortality rate of 2-24
• Occurs in 4-12 of severe preeclampsia

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DX

• Platelet lt 100,000
• Liver enzymes AST ALT elevated
• Evidence of intravascular hemolysis must be
  present

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Complications of HELLP

• Renal failure
• Pulmonary edema
• Ruptured liver hematoma
• DIC
• Abruptio placenta
• Fetal death
• Perinatal asphyxia
• Maternal death

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Sx of HELLP

• Epigastric pain
• Mailaise
• Nausea and vomiting
• Mild jaundice often noted
• Sound like the flu?

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DIC

• Prothrombin time, partial thromboplastin time and
  fibrinogenlevels are normal in patients with
  HELLP
• In a patient with a plasma fibrinogen level of
  less than 300 mg/dL, DIC should be suspected,
  especially if other laboratory abnormalities are
  also present
• Oozing from venipuncture sited, hemorrhage,
  uterine atony

132
DIC

• Systemic thrombohemorrhagic disorder involving
  the generation of intravascular fibrin and the
  consumption of procoagulants and platelets
• Causes in pregnancy abruptio placenta, IUFD with
  retained dead fetus, AFE, endotoxin sepsis,
  preeclampsia with HELLP and massive transfusion

133
TX of DIC

• Replacement of volume, blood products, and
  coagulation components
• Cardiovascular and respiratory support
• Elimination of underlying triggering mechanism
• Anticoagulation
• Replace blood products as indicated-packed RBCs,
  platelets, FFP, cryo
• Antithrombin III concentrate
• Hematology, transfusionist, critical care
  consultants.

134
Treatment for HELLP

• Delivery is the only cure
• Antenatal administration of dexamethasone
  (Decadron) 10 mg IV every 12 hours
• Mag Sulfate bolus of 4-6 g as a 20 soln then
  mainenance of 2 g /hr
• Antihypertensive therapy should be initiated if
  BP gt 160/110

135
Rh Incompatibility

• Rh mother, Rh fetus
• Maternal IgG antibodies produced
• Hemolysis of fetal red blood cells
• Rapid production of erythroblasts
• Hyperbilirubinemia

136
Administration of Rh Immune Globulin

• After birth of an Rh infant
• After spontaneous or induced abortion
• After ectopic pregnancy
• After invasive procedures during pregnancy
• After maternal trauma

137
ABO Incompatibility

• Mom is type O
• Infant is type A or B
• Maternal serum antibodies are present in serum
• Hemolysis of fetal red blood cells

138
Surgery During Pregnancy

• Incidence of spontaneous abortion is increased in
  first trimester
• Insert nasogastric tube prior to surgery
• Insert indwelling catheter
• Encourage patient to use support stockings
• Assess fetal heart tones
• Position to maximize utero-placental circulation

139
Trauma During Pregnancy

• Greater volume of blood loss before signs of
  shock
• More susceptible to hypoxemia with apnea
• Increased risk of thrombosis
• DIC
• Traumatic separation of placenta
• Premature labor

140
Battering During Pregnancy

• Psychological distress
• Loss of pregnancy
• Preterm labor
• Low-birth-weight infants
• Fetal death
• Increased risk of STIs

141
Perinatal Infections

• Toxoplasmosis
• Rubella
• Cytomegalovirus
• Herpes simplex virus
• Group B streptococcus
• Human B-19 parvovirus

142
Fetal Risks Toxoplasmosis

• Retinochoroiditis
• Convulsions
• Coma
• Microcephaly
• Hydrocephalus

143
Fetal Risks Rubella

• Congenital cataracts
• Sensorineural deafness
• Congenital heart defects

144
Fetal Risks Chlamydia

• Neurologic complications
• Anemia
• Hyperbilirubinemia
• Thrombocytopenia
• Hepatosplenomegaly
• SGA

145
Fetal Risks Herpes

• Preterm labor
• Intrauterine growth restriction
• Neonatal infection

146
Fetal Risks GBS

• Respiratory distress or pneumonia
• Apnea
• Shock
• Meningitis
• Long-term neurologic complications

147
Fetal Risks Human B-19 Parvovirus

• Spontaneous abortion
• Fetal hydrops
• Stillbirth